Provider Demographics
NPI:1811305246
Name:REISTERER, BENJAMIN (LPC)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:REISTERER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6916 NORTHLAND DR NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-9609
Mailing Address - Country:US
Mailing Address - Phone:616-460-0871
Mailing Address - Fax:
Practice Address - Street 1:741 KENMOOR AVE SE
Practice Address - Street 2:SUITE B
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2304
Practice Address - Country:US
Practice Address - Phone:616-920-0650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-29
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014274101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional